Coroner's Finding: Richardson, Kenneth Charles

93y · Male·digoxin toxicity complicating acute on chronic renal failure

Kenneth Charles Richardson, a 93-year-old with long-standing cardiac disease (systolic heart failure, atrial fibrillation, mitral regurgitation) died from digoxin toxicity complicating acute-on-chronic renal failure. He presented to hospital following a fall at home with a serum digoxin level of 3.68 nmol/L—well above the therapeutic range. The key clinical lesson: Mr Richardson had not had digoxin levels monitored since December 2010, despite progressive renal function decline over four years. As kidneys deteriorated, they could no longer clear digoxin at the standard dose, causing toxic accumulation. Digoxin has a narrow therapeutic index and requires regular monitoring in elderly patients with declining renal function. The coroner found that appropriate monitoring would likely have detected rising levels and prompted dose reduction. Hospital management was appropriate; this death was preventable through proper primary care monitoring. The coroner recommended regular digoxin level testing every 3-6 months for elderly patients on digoxin for systolic heart failure.